By Sandra G. Boodman
Washington Post Staff Writer
Tuesday, January 23, 2007
For doctors, the continuing education credits required by most states to renew a medical license are a way to bone up on the latest clinical developments while chowing down at some of the country's finest restaurants. For drug companies, which provide much of the more than $1.7 billion spent annually on these dinner meetings and conferences, they are an opportunity to help educate physicians who must remain up-to-date in a rapidly changing field.
But some doctors have complained that industry sponsorship of medical education creates an inherent conflict of interest for physicians at the expense of patients who risk being prescribed drugs they may not need or cannot afford.
"If you're a doctor, you can refuse to see drug reps in your office, but you can't avoid CMEs," said physician Adriane Fugh-Berman, a longtime critic of industry funding of continuing medical education programs. While these courses appear impartial, said Fugh-Berman, an associate professor in the department of physiology at Georgetown University School of Medicine, they can be an integral but largely unscrutinized part of a covert marketing campaign to convince doctors that a disease or condition is pervasive, under-diagnosed and best treated by writing a prescription.
Two weeks ago, armed with a $400,000 grant, Fugh-Berman and several Georgetown colleagues launched PharmedOut, a free, Internet-based alternative for doctors seeking CME courses devoid of industry funding. The site ( http://www.pharmedout.org) lists more than 200 online classes available to doctors at no cost, many of them sponsored by federal agencies such as the Food and Drug Administration and the National Institutes of Health. It also includes links to studies exploring the role of drug company funding in medical education and research, as well as a YouTube interview with a former drug salesman who candidly discusses the ways he deflected doctors' concerns about a widely prescribed psychiatric drug that has been linked to massive weight gain and diabetes.
PharmedOut is one of about two dozen projects across the country designed to teach doctors and nurses to critically evaluate information about drugs and to direct them to unbiased information. The projects are funded by a $21 million grant through the Attorney General Consumer and Prescriber Grant Program, which was created as part of a 2004 settlement by Warner-Lambert involving the drugmaker's illegal promotion of the widely used epilepsy drug Neurontin.
The second phase of the program, which is being administered by the Center for Evidence-Based Policy at the Oregon Health & Science University, will provide similar educational programs targeted at consumers.
Interest in the overt and covert ways drug companies influence doctors has mushroomed in the past few years, experts say, fueled in part by concerns about the safety of prescription drugs, exemplified by the now-withdrawn blockbuster pain medication Vioxx, coupled with the skyrocketing cost of pharmaceuticals. Much of the attention has focused on the influence of salespeople who frequent doctors' offices touting new medicines, dropping off free samples and buying lunch for the staff.
More recently there has been debate about drug companies' influence on the outcome of scientific studies it finances, and on medical education, including residency training programs.
Scott Lassman, senior assistant general counsel of the pharmaceutical trade group PhRMA, said that drug manufacturers do not wield undue influence in continuing education because the content of CME courses is "completely independent" and not designed or dictated by drug companies.
Firms "fund it because they feel it is an important part of medical education," Lassman said, and are fulfilling "a corporate responsibility" by bankrolling courses.
There is no dispute that CMEs are big business. According to the Accreditation Council for Continuing Medical Education, which oversees the courses, more than $1.7 billion was spent on CME programs in 2005, more than double the $842 million reported in 1998.
About $1 billion comes from drug companies, Fugh-Berman noted in an article posted last year in Virtual Mentor, an online ethics journal published by the American Medical Association.
In an interview she said that overt sales pitches are anathema in CME courses because they alienate doctors.
Instead "there are messages that help the drug companies, like 'Osteoporosis is a killer disease and affects one quarter of all women,' '' she said. "The message is that this is real and it affects your patients." Sometimes, she added, CME courses precede the launch of a drug that may be no more effective than those on the market. Older, cheaper generic alternatives or non-drug treatments receive short shrift.
Obstetrician-gynecologist Anthony Scialli said that examples of inappropriate prescribing related to CME courses abound.
"Take oral contraceptives," said Scialli, a reproductive toxicologist who teaches at Georgetown. "Over the years they have increased in number, but there haven't really been any major advances since the 1970s. The newer ones are more expensive. Why do doctors prescribe them? Because of promotion and educational activities" funded by the manufacturers.
The same thing occurred with hormone therapy for post-menopausal women, he said, which for decades was touted as an essential way to stave off heart disease and dementia -- until federally funded research showed the pills were linked to the very conditions they were supposed to prevent.
While industry sponsorship of CME courses is widespread, it is not universal.
At the small, 270-student medical school of East Carolina University in Greenville, N.C., associate dean Stephen Willis has managed to keep industry influence to a minimum. Less than 10 percent of the school's $600,000 CME budget comes from pharmaceutical companies or medical device manufacturers, he said.
"I'm ethically opposed to commercial support of CMEs," said Willis, a family physician. "I just deal with too many people who have to choose between heat in the wintertime or paying for drugs.
"Most taxpayers have no idea that they could pay less for their drugs if the pharmaceutical companies took the couple of billion dollars they spent subsidizing CME and used it to reduce the cost of drugs," he added.
Willis said he thinks doctors should pay for CME courses themselves.
So does Fugh-Berman, who notes that they are a tax-deductible expense.
"The education of physicians should be funded by physicians, not by a third party whose profits are directly related to prescribing behavior," she wrote. "Weaning CME from the industry breast is like striving to meet our energy needs without oil -- tough but necessary." ·